More than a year ago, she lost her job at a nearby rural hospital after it closed and, as Republicans work to dismantle the Affordable Care Act, wonders whether she’ll soon be out of work again.

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“Many of my friends did not find jobs they love,” she said. “They’re working for less money or only part time. Some haven’t found any jobs yet, even after a year.”

Now she runs the pharmacy at Perry Memorial Hospital here, warily watching the Republicans’ repeal efforts.

“I think everybody who works in health care now feels a little uneasy,” said Chapman. “We don’t know what’s coming around the corner, and how it will affect us. But we know that change is happening so fast, it is exhausting and difficult to keep up with.”

Rural hospitals have long struggled to stay open. They have far fewer patients and thin profit margins. Dozens have closed across the country in recent years, mostly in states that didn’t expand Medicaid.

But in Illinois, which did extend Medicaid to nearly all poor adults, patients at Perry Memorial have gained coverage under the Affordable Care Act and many hospitals have found firmer footing.

If large numbers of people lose their insurance under the Republicans’ replacement, the hospital’s finances — and those of its patients — would be at risk, especially after the hospital invested so much money and time in complying with the health law, said chief executive Annette Schnabel.

“We have spent the last six years gearing up towards everything that we were responsible for doing in the ACA,” said Schnabel. If the hospital has to “totally go a different direction, how will we do that? It’s going to take a lot of work.”

And for some hospitals to survive or break even, it would require Congress to restore billions of dollars in funding that kept hospitals afloat before the 2010 law took effect.

Hospitals across the country made a high-stakes trade when they signed on to the Affordable Care Act. They agreed to massive cuts in federal aid that defrayed the cost of caring for the uninsured. In exchange, they would gain tens of millions of newly insured customers. Now that deal is in jeopardy, and many hospital executives anxiously await whatever comes next.

In states that have seen growth in the number of insured patients, hospitals have invested in new equipment and hired more employees.

In Chicago, John H. Stroger Jr. Hospital of Cook County is among the nation’s busiest hospitals, handling most of the city’s gunshot victims. The vast majority of its patients used to be uninsured, and the county-run hospital struggled to take care of their medical and mental health needs.

Those patients now have Medicaid coverage because of the Affordable Care Act, and the Cook County hospital system gained $200 million in new revenue to cover their services, breaking even for the first time.

“We have no interest in slipping back in what we’ve been able to do,” said Dr. John Jay Shannon, chief executive of the Cook County Health and Hospitals System. “We’re not able to do the kind of work that we do today with good will alone. Our staff are not a volunteer staff. We can’t get IV fluids and medical equipment on credit and a wink and a nod.”

Two hospital trade groups — the American Hospital Association and the Federation of American Hospitals — have warned of “an unprecedented public health crisis” if the law gets hastily scuttled.

They say if Congress repeals the law entirely and 20 million people are kicked off their insurance, hospitals will lose $166 billion in Medicaid payments alone in the next decade.

And hospitals face much steeper losses if certain Medicare cuts that were part of the law aren’t restored.

In Chicago, limo driver Jerold Exson is one patient who could lose coverage and have his hospital bills — once again — go unpaid. These days, the hospital helps enroll low-income adults such as Exson into Medicaid. In 2014, he was shot nearly a dozen times in a case of mistaken identity.

His medical care is now covered, and the hospital can provide follow-up surgeries, physical therapy and mental health treatment that were often off-limits to the uninsured.

Clinical psychologist Natalia Ruiz helps Exson manage the after-effects of gun violence. “I used to be real antsy,” said Exson who suffers from post-traumatic stress disorder. He recalled a recent moment when he was driving and a “rock hit the window, and it kind of sent me into a tailspin.”

The health law also shifted the business model for U.S. hospitals. It offered them financial incentives to move away from expensive ER visits to primary care and managing chronic conditions.

Earl Williams Sr. finally has brought his diabetes under control. He’s diligent about exercising, taking his medication and seeing his doctor.

“I had high sugar levels, I had high blood pressure, there was quite a few things that was going on with me that now I know how to control,” said Williams.

Before the Affordable Care Act, hospitals had little incentive to reduce emergency department visits, especially from Medicare patients who generate a lot of revenue.

At University of Chicago Medicine, an academic medical center, Dr. Kenneth Polonsky said if those incentives are rescinded and patients forgo preventive care, they’ll clog up already strained emergency rooms.

“We’ll go back to a very frustrating time, where people had limited options for health care, because of inability to get health insurance,” said Polonsky, dean of the Division of the Biological Sciences.

The uncertainty is also roiling county governments, which often fund medical care for the poor.

The burden on local taxpayers to fund the Cook County health system has dropped by $300 million since the health law went into effect, and repealing the law could force local governments to raise taxes.

The political uncertainty surrounding health care is roiling county governments, which often fund care for the poor.

“It’s a $300 million hole in our budget,” said Toni Preckwinkle, president of the Cook County Board of Commissioners. “There aren’t a lot of options other than raising more revenue. It’s a nightmare for us.”

In Waukegan, Ill., near the Wisconsin border, Vista Health System chief executive Barbara Martin said that with more patients covered and additional reimbursement from the ACA, she has invested in new equipment and hired hundreds of new employees across Vista’s two for-profit hospitals.

She said if the 900,000 Illinois residents who gained insurance under the law lose coverage — and hospital revenue drops suddenly — hospital executives estimate 95,000 jobs could be lost.

“That certainly would impact jobs at Vista,” Martin said. “We’re going to go back to those days where hospitals were closing.”

But Edmund Haislmaier, a senior fellow at the Heritage Foundation, a conservative think tank, said the U.S. already pays too much for health care. A member of President Donald Trump’s transition team on health policy, Haislmaier said communities — and states and local governments — shouldn’t rely on hospitals to create jobs and fill budget holes.

“Hospitals, in particular, have become economic development projects,” he said. “If you’re paying tax dollars for Medicare or Medicaid, treating that as an economic development project is a problem, not a benefit.”

Earl Williams is diligent about seeing his doctor, but worries whether he will have health insurance after Republican changes to the ACA.

More than a dozen top Republican lawmakers declined to be interviewed for this story. But a spokeswoman for Sen. Lamar Alexander, the Tennessee Republican who chairs the Senate Committee on Health, Education, Labor and Pensions, said in a statement that Alexander “is listening to hospitals, doctors, patients, state insurance commissioners, governors” as they draft the replacement plan.

The most recent draft of the Republican’s proposal would eliminate the Medicaid expansion, which covers 14 million people, by 2020. To offset the increase in uninsured patients, the plan would reverse some of the payment cuts to hospital.

Back in Chicago, patients like Earl Williams have been bringing their questions to their doctors, with the hope of some clarity.

At a recent checkup, Williams asked pointedly, “Am I going to have insurance in a month or two? That’s kind of scary for brothers that’s in the community.”

“You and I have been knowing each other for a long time, and I’m going to give it to you straight,” responded William’s physician, Dr. Pete Thomas. “And that is: It’s likely that it’s going to change. It’s not going to be the same.”

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